Screening in Primary Care_summer 2021-1.pptx

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1. Screening in Ambulatory Care Caroline V. Coburn, DNP, MS, ANP-BC N432 Ambulatory Care Summer, 2021

2. Objectives Identify and apply the general principles for appropriate use of screening in primary care. Appropriately apply selected screening guidelines for use in primary care. Understand the screening principles for substance misuse. Discuss the potential ethical and/or controversial issues related to screening, and the role of nursing.

3. Lifetime Cumulative Risk – based on this, where should our screening money go? Harrison’s Principles of Internal Medicine Breast cancer for women 10% Colon cancer 6% Cancer of the cervix for women 2% Domestic violence for women Up to 15% Hip fracture for white women 16%

4. Screening Principles Screening can be used to identify an unrecognized disease or risk factor in a seemingly well person. Can you treat it? Worth the cost and effort on a national/global level? Does early detection matter?

5. From the Reading: Is It Worthwhile? The burden of disease must be sufficient to warrant screening. The test used for screening must be of high quality. There should be evidence that screening reduces morbidity or mortality.

6. Determining the Benefits Look at both the absolute and relative impact on incidence or mortality. Consider number of subjects screened to prevent disease or death in one individual. Similar to number needed to treat. Consider increase in life expectancy for a population. Sensitivity: the ability of a test to detect any possibility of a disease – decreases false negatives. Casting a wide net. Specificity: the ability of a test to identify the specific disease in question – decreases false positives. But may miss some. Why does it matter? Weight the pros and cons of both the test and the disease being screened.

7. What are the common themes? What is the difficulty? “The needs of the many outweigh the needs of the few.” (???) Mr. Spock, Star Trek, TOS

8. Any Ethical Issues in Screening? What if you have no treatment available? What if you’re not sure the screening test is unbiased? What if the client refuses screening (or vaccination, or any other tx ) even when medically important? What if the client wants to screen for every possible disease, whether appropriate or not? COVID screening – when? What then? Screening for treatment: use of racial and gender algorithms

9. Screening Guideline Examples: Colorectal Cancer USPSTF: The USPSTF recommends screening for colorectal cancer starting at age 50 years and continuing until age 75 years. ACS: For people at average risk for colorectal cancer, the American Cancer Society recommends starting regular screening at age 45 . Breast Cancer USPSTF: The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Women with a parent, sibling, or child with breast cancer are at higher risk for breast cancer and thus may benefit more than average-risk women from beginning screening in their 40s. ACS: Women ages 40 to 44 should have the choice to start annual breast cancer screening with mammograms if they wish to do so. Women age 45 to 54 should get mammograms every year. Women 55 and older should switch to mammograms every 2 years, or can continue yearly screening.

10. Screening Guideline Examples Prostate Cancer – Use of PSA: treatment vs screening USPSTF: For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)–based screening for prostate cancer should be an individual one (including family hx , race/ethnicity, comorbid conditions). Clinicians should not screen men who do not express a preference for screening. ACS: Starting at age 50 , men should talk to a health care provider about the pros and cons of testing so they can decide if testing is the right choice for them. If you are African American or have a father or brother who had prostate cancer before age 65, you should have this talk with a health care provider starting at age 45.

11. Screening Guideline Examples Falls: The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. STEADI –Stopping Elderly Accidents, Deaths, and Injuries TUG: Timed Up and Go SDoH : PRAPARE, Screening for social determinants of health: from the National Association of Community Health Centers http://www.nachc.org/research-and-data/prapare/

12. Specialty Organizations American Heart Association/American College of Cardiology http://www.acc.org/#sort=%40fcommonsortdate86069%20descending American Academy of Family Physicians http://www.aafp.org/patient-care/browse/all-recommendations-topic.html American Cancer Society https://www.cancer.org/healthy/find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html

13. Screeners for Screening US Preventive Services Task Force https://www.uspreventiveservicestaskforce.org/BrowseRec/Index An independent panel of experts in primary care and prevention, now under the aegis of the Agency for Healthcare Research and Quality (AHRQ) Supported by outside experts, several evidence-based practice centers, and university centers that help identify high-priority topics, produce systematic reviews, and draft guidelines. USPSTF guidelines often form the basis of clinical guidelines developed by professional societies.

14. Screeners for Screening National Guideline Clearinghouse http://www.guideline.gov/ A public resource for evidence-based clinical practice guidelines Sponsored by the AHRQ and US Department of Health and Human Services A way to access and compare a variety of guidelines, including those written by USPSTF, professional societies, and other private organizations